Should Universal Health Care Really Be Universal?

Ryan Avent says that “we should all be ashamed” that Barack Obama felt the need, in his interview with conservative talk-radio host Michael Smerconish, to debunk the rumor that his health plan will offer health insurance to illegal immigrants. This refusal to insure anyone and everyone who comes to America is, Ryan says, “enough to make a man lose his faith in people.”

Well, maybe, but if that’s the case, I’m pretty sure Ryan would have lost his faith in people a long time ago, since none of the big European states that we traditionally look to as models of successful universal health care insure illegal immigrants, either. On the contrary, like the U.S., they limit illegal immigrants’ unpaid access to health care to precisely those situations Obama alluded to in his interview: emergencies and public-health risks, like infectious diseases. Given that we’re in the middle of a huge struggle just to get the U.S. close to where European countries already are in terms of the universality of insurance, it seems a bit much to ask that we should go far beyond what those countries are doing, and extend insurance to literally anyone who makes it across the border.

Even if you set the political calcuation aside, it’s not obvious to me that the case for insuring illegal immigrants is as open-and-shut as Ryan makes it out to be. Actually, he doesn’t make the case for it—he just assumes that opposing insurance for illegal immigrants is a shameful, inhuman position. (Here, by contrast, is a sustained argument [pdf] that E.U. countries should open their health-care systems to all immigrants.) The success of the welfare state in Europe and the U.S. (limited as it is) has been built, in large part, on ideas of citizenship and national solidarity. Now, maybe those are ideals that we should look to wipe away, in favor of a more transnational conception of responsibility, but it’s not obvious that you can do this and keep meaningful welfare states intact. More practically, offering insurance to anyone who comes to the U.S. would obviously create all kinds of complicated incentives for people to migrate here when they were sick, particularly since no other major industrial democracy offers insurance for illegal immigrants. Ryan in effect is arguing that U.S. citizens should pay for the health care of anyone who wants to come here, turning us into the health-care provider of last resort for the rest of the world. It’s a nice thought, but I’m not really sure it’s shameful to think that it’s a bad idea.

James Surowiecki is the author of “The Wisdom of Crowds” and writes about economics, business, and finance for the magazine.